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Official URL: http://ns.electronichealth.net.au/fhir/cn/ImplementationGuide/au.digitalhealth.r4.agedcareclinicalnote Version: 0.1.0-preview
IG Standards status: Draft Maturity Level: 0 Computable Name: AgedCareClinicalNote

Usage:Jurisdiction: Australia

Copyright/Legal: Copyright © 2025 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/.

Aged Care Clinical Note FHIR Implementation Guide

Draft Implementation Guide

This Implementation Guide is currently in DRAFT status and is not intended for production use. The content may change before formal publication.

The clinical note document provides a consistent method of passing clinical information from one healthcare organisation to another in a safe and secure method using existing point-to-point transfer mechanisms.

The implementation guide was derived from the information requirements and business requirements document published on the Agency developer portal.

Introduction

This guide is a collection of HL7® FHIR® Release 4 (R4) artefacts authored and maintained by the Australian Digital Health Agency.

The goal of the Aged Care Clinical Note document is to provide a consistent method for passing clinical information relevant to an aged care setting from one healthcare organisation to another in a safe and secure manner using existing point-to-point transfer mechanisms. It aims at addressing an identified gap in how healthcare organisations transfer health information between aged care clinical information systems (CIS) where a standard format does not exist.

This Implementation Guide outlines scenarios where the Aged Care Clinical Note document is beneficial and recommends a structured format using FHIR artefacts. At this stage, it doesn't provide any guidance on how the Aged Care Clinical Note document may be exchanged. It assumes that already established exchange mechanisms will continue to be used in the first instance.

Overview

The development of the clinical note document has emerged from the Aged Care Clinical Information Systems (ACCIS) Standards, which responded to recommendations 68 and 109 of the Royal Commission into Aged Care Quality and Safety. The development of the ACCIS Standards identified a gap in how healthcare organisations transfer clinical information to and from an aged care clinical information system (CIS) to another clinical software system where a standard format does not already exist.

The development of the clinical note document supports and aligns with interoperability as a strategic priority in the Australian National Digital Health Strategy, as outlined in the National Healthcare Interoperability Plan 2023-2028, which states that interoperability of clinical information is essential to high-quality, sustainable health care in which clinical information is collected in a prescribed manner and can be shared in real time with patients and their providers.

Specifically, Action 3.5 in Priority Area 3 – Information Sharing is to assess the current interoperability between GP and residential aged care facility systems, identifying issues, requirements and potential solutions to resolve issues.

The clinical note document also aligns with Outcome 3 of the Aged Care Data and Digital Strategy 2024-2029: Data is shared and reused securely to deliver a sustainable and continually improving aged care system. Best efforts were made to align the Clinical Note document to the National Minimum Data Set v1.

Standards create consistency and compatibility, support a single source of truth, and enable interoperability. This document describes the scenarios and business requirements for the clinical note document, leveraging existing standards and infrastructure.

Efforts to standardise software systems aligns to the interoperability principles stated in the National Healthcare Interoperability Plan (Agency2023). The sections in this document specifically aligns to the following interoperability principles:

  • health information is discoverable and accessible
  • national healthcare identifiers are used across the healthcare sector
  • national digital health standards and specifications are agreed and adopted
  • core national healthcare digital infrastructure is used across the sector
  • collaboration and stakeholder engagement underpin interoperability.

The standardising of software systems needs to reflect the above interoperability principles.

How to read this guide

This guide is divided into several pages which are listed at the top of each page in the menu bar.

  • Home: This page provides the introduction and scope for the Implementation Guide.
  • Use Cases: This page highlights some potential use cases for the Aged Care Clinical Note document.
  • Conformance: This page describes the set of rules to claim conformance to this guide including the expectations for Mandatory and Must Support elements.
  • Guidance: These pages provide additional guidance on some topics to ensure a clearer pathway for consistent implementation by adopting organisations. These topics are:
    • Terminology: This page provide guidance on some key terminology concepts that are key for interoperability.
    • Author and Recipient: This page provides guidance on how to represent authoring and receiving parties of the Aged Care Clinical Note document.
  • FHIR Artefacts: These pages provide detailed descriptions and formal definitions for all the FHIR artefacts defined in this guide.
  • Examples: This page lists all the examples used in this Implementation Guide.
  • Downloads: This page provides links to downloadable artefacts including the Agency FHIR NPM package.
  • Disclaimers: This page lists the licensing, copyright, and disclaimers under which this guide is issued.

Relationships with other work

This implementation guide builds on other specifications, helping ensure a consistent approach to data sharing that should ease adoption. The specific guides used, and the portions relevant from each of them are as follows:

Intellectual property considerations

This implementation guide and the underlying FHIR specification are licensed as public domain under the FHIR license. The license page also describes rules for the use of the FHIR name and logo.

This publication includes IP covered under the following statements.